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Archives of Sexual Behavior

, Volume 48, Issue 1, pp 3–30 | Cite as

Rethinking Risk, Culture, and Intervention in Collective Sex Environments

  • Katherine FrankEmail author
Target Article

Abstract

This article provides a narrative overview of research on HIV/STI risk and collective sexual behavior based on an inclusive analysis of research on environments where people gather for sexual activity—sex clubs, swingers’ clubs, bathhouses, parks, private sex parties, etc. The aim is to analyze how collective sex has been approached across disciplines to promote conversation across paradigms and suggest new lines of inquiry. Attention to context—such as the location of sex—was a necessary redress to universalizing models of sexual risk-taking behavior, leading to insights rooted in the particularities of each environment and its users. However, the identification of ever more precise risk groups or environmental idiosyncrasies eventually becomes theoretically restrictive, leading to an overestimation of the uniqueness of sexual enclaves, and of the difference between any given enclave and the broader social milieu. Using a theoretical framework of transgression to interpret the interdisciplinary literature, similarities in the spatial and social organization of collective sex environments are identified. Insights generated from this complementary perspective are then applied to understandings of collective sex: first, the example of male–female (MF) “swingers” is used to illustrate the need to establish, rather than assume, the distinctiveness of each non-normative sexual enclave, and to broaden the conceptualization of context; second, questions are raised about the practicality of interventions in collective sex environments. Finally, new lines of intellectual inquiry are suggested to shed light not just on collective sex but on sociosexual issues more generally, such as increasing protective sexual health behavior or negotiating consent in sexual encounters.

Keywords

Group sex Venues Sexual risk-taking Sexually transmitted infections Sexual behavior 

Abbreviations

Venue Type

CSV

Commercial sex venue

GSE

Group sex event

PSE

Public sex environment

PSV

Public sex venue

SOPV

Sex on premises venue

Risk Behavior

CAS

Condomless anal sex

CAI

Condomless anal intercourse

CLAIC

Condomless anal intercourse with casual partners

CVI

Condomless vaginal intercourse

PAI

Protected anal intercourse

PNP

Party and play

sdUAI

Serodiscordant unprotected anal intercourse

sdUAS

Serodiscordant unprotected anal sex

UAI

Unprotected anal sex

UI

Unprotected intercourse (vaginal or anal)

UIAI

Unprotected insertive anal intercourse

URAI

Unprotected receptive anal intercourse

UVI

Unprotected vaginal sex

Other

BDSM

Bondage/domination/sadism/masochism (umbrella term)

CNM

Consensual non-monogamy

CT

Chlamydia trachomatis

GBM

Gay bisexual men

GSS

General Social Survey

HCV

Hepatitis C

HIV

Human immunodeficiency virus

HPV

Human papillomavirus

HRH

High-risk heterosexuals

IDU

Intravenous drug user

MF

Male–female (MF couples might be heterosexual or composed of MSMW and/or WSMW; MF environments are designated as such based on assumed biological sex of participants)

MSM

Men who have sex with men

MSMW

Men who have sex with men and women

NG

Neisseria gonorrhea

PrEP

Pre-exposure prophylaxis

STD

Sexually transmitted disease

STI

Sexually transmitted infections

WSW

Women who have sex with women

WSMW

Women who have sex with men and women

Introduction

This article synthesizes research on human immunodeficiency virus and sexually transmitted infection (HIV/STI) risk and collective sexual behavior based on an inclusive analysis of research on environments where people gather for sexual activity—sex/swingers’ clubs, bathhouses, parks, private sex parties, etc. In any environment, individuals might engage in dyadic sex, consecutive sex with multiple partners, and/or group sexual activity. Research on collective sex draws on numerous theoretical traditions, employing quantitative, qualitative, ethnographic, and mixed methods. Due to the size and interdisciplinary nature of the literature, this is a critical, narrative overview rather than a comprehensive or systematic review (Baumeister & Leary, 1997; Grant & Booth, 2009). A narrative overview is a qualitative analysis of primary studies across disciplines and methodologies that can promote conversation across paradigms and point to new directions for research and theory (Green, Johnson, & Adams, 2006).

Existing research tends to differentiate between environments based on participants. All-male environments have been studied most frequently. Men who have sex with men (MSM) are more than 40 times more likely to be infected with HIV than other men in the U.S. according to the Centers for Disease Control and Prevention (CDC), comprising 70% of new infections in 2014 (CDC, 2017). Even high-risk heterosexuals (HRH) have less risk of HIV than gay or bisexually identified men (GBM) and MSM, although other STIs remain a public health issue (Mark, Dhir, & Roth, 2015). Collective sexual behavior also has important political and historical meanings in gay communities (Bérubé, 2003; Prior & Cusack, 2008) and remains widespread among some MSM (Grov et al., 2014b; Reisen, Iracheta, Zea, Bianchi, & Poppen, 2010). Further, collective sex environments are overwhelmingly stratified by assumed biological sex rather than identity, gender presentation, sexual orientation, or sexual behavior. Venues for men usually refuse entry to male–female (MF) couples or women, with varying policies on trans-individuals; other venues or events restrict entry to MF pairs or singles, although the behavior of attendees ranges from heterosexual to same-sex activity (Albury, 2015; Harviainen & Frank, 2016). MF couples do not publicly “cruise” to the same extent as MSM, although they have sex in public or semipublic locations (taxis, restrooms, etc.). As physical venues catering only to women are limited, women who have sex with women (WSW) may visit MF sex clubs, appropriate male bathhouses, or attend swinging or BDSM parties (Albert, 2011; Brown & Gailey, 2016; Nash & Bain, 2007).

As predominant theoretical frameworks analyzing collective sex environments emphasize the interaction of context and sexual behavior, existing research also tends to distinguish between types of environments: for example “public sex environments” (PSEs, or public spaces used for sex by some individuals in addition to serving other functional purposes, such as saunas, gyms, parks, or public restrooms, also referred to as “erotic oases,” Tewksbury, 2010); “sex on premises venues” (SOPVs, or places intended or used regularly for sex, such as bathhouses or sex clubs); and “group sex events” (GSEs, which can occur in any environment, commercial or private, and include sex parties, “swinging” or lifestyle parties where MF couples engage in extradyadic sex, informal gatherings where multi-person sex occurs, etc.).

The question of precisely how the location of sex affects sexual risk-taking has generated a vast literature; two relatively distinct trajectories are investigated here. In the first trajectory—primarily quantitative and often focused on MSM—collective sex environments are theorized as influencing HIV/STI transmission risk through multiple potential pathways: inherent risks and/or onsite sexual behavior; venue-specific characteristics (physical, architectural, or atmospheric) and norms; and through the attraction of “high-risk” individuals, groups, subcultures, or networks to these settings. Attending to the social and cultural phenomena shaping sexual behavior and meaning in specific contexts challenges universalizing models of risk, helps explain situational variability in behavior that social cognitive theories cannot always address (Rendina, 2015), and complicates a traditional health psychology focus on individual behaviors and characteristics—such as knowledge/education, attitudes, risk perception, and personality factors (Meunier, 2014; Pollock & Halkitis, 2009). Further, site-specific analyses allow for health interventions addressing the unique characteristics of each setting and its users, taking individual, contextual, structural factors that impact risk-taking into account (Grov, Cruz, & Parsons, 2014a; Noar, 2008). As one must eventually contend with the idiosyncratic features of each given environment or individual differences between group members in actual risk-taking behaviors and infections, this literature tends toward increasing particularity.

The second trajectory—primarily ethnographic, observational, and qualitative—centers on the social and sexual organization of behavior, interactional patterns, and meaning-making in collective sex environments. Prior to the HIV epidemic, scholars studied collective sex environments as sites of deviant subcultures. Studies of male same-sex cruising in public parks, highway rest areas, and other locales generated analyses of the spatial patterns and interactional norms resulting from participants’ needs for safety and discretion (Corzine & Kirby, 1977; Delph, 1978; Humphreys, 1975). Occasionally, analyses rooted in deviance theories continue to emerge (Tewksbury, 1996, 2002) although recent decades have also seen collective sex analyzed using literary/critical theory, feminist theory, geography, queer theory, and other frameworks. This literature also tends toward increasing particularity as researchers select a single field site, or a small number of sites, to investigate, focusing on the most visible and accessible environments. Sex clubs, bathhouses, and highway rest areas are studied more frequently than college campus PSEs (restrooms, libraries, or gyms), for example, even though campus locations are more numerous (Tewksbury, 2008). The diffuse influence of symbolic interactionism, a primarily micro-level theoretical framework frequently used to examine how the environment influences the development of the self, behavior, and symbolic meanings (Carter & Fuller, 2016), further heightens the emphasis on specific interactions and contexts.1

A shift to exploring the context of risk-taking behavior was meant, in part, to address the limitations of “culture” or “subculture” as a partial explanation of how risk is variably distributed across populations. Recognizing the problems with viewing all gay or bisexual men as members of a risk group sharing a “high-risk culture” even if they did not engage in behavior that transmitted HIV (Schiller, Crystal, & Lewellen, 1994), researchers turned to looking at risk-taking in specific contexts—sometimes abandoning the word culture altogether. Unfortunately, however, the assumption that people who share physical space will uniquely share other relevant characteristics often persists unquestioned. Collective sex deviates from mainstream norms and expectations so strongly that concepts of culture and subculture often slip back into the analysis ad hoc, undefined and undertheorized; this tendency is exacerbated by an emphasis on context that tends to stop at the walls of a sex club or the edge of a highway PSE. What precisely is shared among users of collective sex environments, and how these shared elements both differ from those of the mainstream and relate to HIV/STI risk, is rarely directly addressed, or is conceptualized differently across studies. This oversight can lead to an overestimation of the distinctiveness of each sexual enclave, from each other and from the mainstream, a problem with theoretical and practical implications.

An inclusive analysis of collective sex environments across time, place, and participant sexual orientations provides a complementary perspective acknowledging the rich variation emerging from the existing literature while also identifying underlying similarities with implications for sexual risk-taking. The term “collective sex environments” sidesteps the inconsistent categorization of environments across studies (Melendez-Torres, Nye, & Bonell, 2016), and the difficulty classifying sexual encounters as “group” or “public,” given that sexual encounters may involve multiple configurations of participants and witnesses. Sexual activity can be interpreted as public or private not just because of location but regarding other physical or symbolic attributes (Leap, 1999), such as access (i.e., city parks or private homes; “open-door” vs. invitation-only events), visibility, with sexual activity ranging from being easily observable to relatively discreet in the sense that witnesses can be discouraged through landscape features, doors, and so on, or legality. “Dogging” is a British slang term for public or semipublic sex involving multiple potential MF participants and voyeurs. At dogging sites, sexual activity may occur between couples and groups outdoors in parking lots or other places accessed by automobiles (relatively publicly) or inside cars (relatively privately). For participants, practical and erotic differences arise between scenarios; legally, however, participants may be culpable either way.

The anthropological framework of transgression used here has continuities with theories of deviance, as it is concerned with the regulation and social organization of behavior. Despite variation, all collective sex environments can be considered transgressive. Taboos exist across time and place regarding exposure of the genitals, contact with body fluids, multiple consecutive sexual partners, and public sexual behavior. Having sex intentionally in the presence of observers or with multiple partners is widely stigmatized, pathologized, and at times criminalized; places where collective sex occurs have long been policed in the name of the social order or morality, not just public health. Historical and anthropological records infrequently include accounts of collective sex occurring in ritual or religious worship, where it was bounded spatially and temporally, or arising in response to natural or social upheavals, although such examples are often problematic to interpret (Frank, 2013). Contemporary examples of widespread social acceptance of collective sex are nonexistent, even if participants do not always interpret their behavior as personally transgressive. Repeated intentional transgression poses risks such as stigma, violence, or legal penalties, and, as such, people who purposely break taboos will seek or create environments that make that behavior both possible and safer to undertake. Across collective sex environments, similar spatial and behavioral patterns thus arise as participants strive to manage physical, social, and emotional vulnerabilities while negotiating sex.

An anthropological framework of transgression also has continuities with materialist, rather than deconstructionist, strains of queer theory that shift the analysis away from “deviant” people, places, or practices and toward the wider social, economic, and political context within which such categorizations are generated. Queer theorists have explored the regulation of non-heteronormative sex—promiscuous, non-dyadic, anonymous or casual, non-domestic, etc.—as sustaining power relations (Berlant & Warner, 1998; Rubin, 1984) and analyzed how concepts of space and place are intertwined with dominant ideologies and power relations such that particular forms of sexuality are privileged over others (Hubbard, 2015; Oswin, 2008).

Section I of this article presents the quantitative literature on sexual risk-taking across populations and environments and discusses the theoretical and methodological complications arising from the dynamic nature of sex-seeking. Section II integrates qualitative, ethnographic, and observational research to illuminate similarities in the patterns of spatial and sociosexual organization arising across collective sex environments. Section III uses insights generated from an inclusive perspective to complement existing understandings of collective sexuality. First, the example of MF “swingers” illustrates the need to establish, rather than assume, the distinctiveness of non-normative sexual enclaves, as theoretical consistency requires attention to a broad social context. Second, practical questions are raised about the validity of onsite interventions in collective sex environments, given the widespread patterns of spatial segmentation and progression and behavioral norms that can be observed across sites. Finally, Section IV suggests new lines of inquiry that could shed light not just on collective sex but on more general sociosexual issues, such as increasing protective sexual health behavior or negotiating consent in sexual encounters.

Method

Analyzing literature across disciplinary boundaries can be time-consuming due to a lack of familiarity with research methods, theoretical approaches, or jargon, and the process of “making sense” of a complex topic area is interpretive and iterative, requiring multiple cycles of searching the literature and synthesizing insights across fields and disciplines (Jamal, Bertotti, Lorenc, & Harden, 2015). The analysis here is primarily limited to peer-reviewed journal articles, even though research on collective sex environments also appears in monographs, edited volumes, unpublished conference papers, and dissertations. Searches for relevant articles were conducted on Google Scholar and in an aggregate academic database which included Academic Search Premier, Anthropology Plus, PsycARTICLES, PubMed, SocINDEX, and Sage Journals Online using combinations of terms such as “risk” and “group sex,” “bathhouses,” “sex clubs,” “public sex,” “sex venues,” and “swinging”. Limited table of contents searches were conducted in journals such as AIDS and Behavior, Sexually Transmitted Infections, and Archives of Sexual Behavior, and the references of relevant articles were scanned for additional citations.

Articles were included if any type of collective sex environment or its users was discussed; methods and findings were summarized in a working table. The Internet is often considered a venue (Brown, Pugsley, & Cohen, 2015), but this research is only included if physical environments were also addressed. Not all MF lifestyle couples, MSM “barebackers,” or BDSM practitioners have experience with collective sexuality; thus, not every publication on these groups was relevant. And finally, the focus here is on recreational settings, although collective sex also occurs in compulsory rituals or coercive or violent transgressions (Dickson-Gomez, Quinn, Broaddus, & Pacella, 2017; Mimiaga et al., 2015a; Njue, Voeten, & Remes, 2009). The Western focus of existing research is an unfortunate constraint, as collective sex is not unique to these populations. More than 239 articles referencing collective sex environments or their users were identified, drawing on research from countries including Argentina, Australia, Belgium, Canada, China, England, Finland, France, Germany, Greece, India, Italy, Kenya, Mexico, Mozambique, Norway, Portugal, Scotland, South Africa, Spain, Sweden, Taiwan, Thailand, the Netherlands, Vietnam, and the U.S. To reflect changing conceptualizations of risk-taking that have accompanied developments in the prevention and treatment of HIV, citations in Section I are limited to studies published after 2005. Section II presents a thematic synthesis of studies across disciplines (Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005) to generate conceptual insight into the organization of collective sex environments. Articles were interrogated for evidence regarding patterns of spatial and social organization regardless of whether those insights were central to the objectives of the primary study. Theoretical saturation was easily attained, and although citations are limited for reasons of space, additional references could have been cited to support each observation. When possible, a review article is cited instead of individual studies and citations reflect consistency across time from the 1970s to the present.

Section I: Risky Places, Risky People?

Collective sex environments have been conceptualized as inherently risky environments, as conducive to or discouraging of sexual risk behavior through venue-specific characteristics (physical, architectural, or atmospheric) and norms, and as sites frequented by “high-risk” groups, subcultures, or networks.

Risky sexual behaviors are those which increase the possibility of transmission of HIV/STIs. Although frequently referred to in the literature as “unprotected” vaginal or anal intercourse (UVI or UAI), a more precise phrasing for the practice of interest would be “condomless” vaginal or anal intercourse (CVI or CAI/CAS). Other considerations of risk-taking consider the relational status of the sexual partner (specifying condomless anal intercourse with casual partners, or CLAIC), sexual positioning (differentiating between unprotected receptive or insertive anal sex, URAI or UIAI), HIV status (serodiscordant unprotected anal sex, sdUAI/sdUAS), and so on, to account for safer sex strategies. Oral sex or swallowing semen is sometimes discussed as a risky sexual practice, although transmission risks are low for HIV and variable for other STIs; oral sex is infrequently related to oropharangeal cancer through transmission of HPV (Nguyen et al., 2016). In general, oral sex is perceived as less risky and practiced without barriers across sexualities and locales (Fridlund, Stenqvist, & Nordvik, 2014; Lefkowitz, Vasilenko, & Leavitt, 2016). Felching, fisting, anal nudging, anal fingering, using semen on the face or body, and other behaviors are occasionally assessed (Grov, Rendina, Ventuneac, & Parsons, 2013b; Phang et al., 2008; Prestage et al., 2009b; Rice et al., 2016b).

Inherent Risks

Collective sex is sometimes considered inherently risky due to the possibility of multiple sequential or simultaneous sex partners, which theoretically allows “for exposure to multiple potential sources of disease in a very short time period,” multiple or “third party” transmission events through infected fluids, and tissue damage due to multiple vaginal or anal sex acts that can make transmission more likely (Friedman, Mateu-Gelabert, & Sandoval, 2011; Rice et al., 2016a).

Some researchers argue that the potential for having sex “with serostatus-unknown partners (either protected or unprotected)” and drug use at GSEs are also “inherent risks” (Phillips et al., 2014). The “intense sensuality” of collective sex environments has been posited as a “catalyst,” potentially interacting with individual-level cognitions and leading to elevated numbers of sexual partners, unintended drug use, and sexual risk-taking through disinhibition, peer influence, or desires for cognitive escape (Downing & Hirshfield, 2015; Pollock & Halkitis, 2009; Solomon et al., 2011). The relationship of drug use to sexual risk-taking and HIV/STI transmission is complex, as substance use potentially affects not just behavior but one’s immune system, mucosal lining, hygiene, and adherence to existing treatment plans (Perry, Taylor, Elsesser, Safren, & O’Cleirigh, 2016), as well as the spread of drug-resistant viral strains (Gorbach, Javanbakht, Bornfleth, Bolan, & Blum, 2017). STIs also interact with each other, increasing the chances of transmission to individuals with weakened immune systems, sores, or lesions.

However, environments can also support safer sex. Many bathhouses and sex clubs promote “safer sex” norms and provide condoms and educational materials on premises (Dunn, 2011; Woods, Euren, Pollack, & Binson, 2010). Participants can implement risk reduction practices such as sharing STI or viral load information, using condoms with each partner and on sex toys, changing condoms and washing between partners, avoiding communal lubricant, withdrawing before ejaculation, hand washing, and mouth rinsing. Serosorting can be facilitated in collective sex environments by limiting access (“POZ” parties for HIV+ MSM), verbal discussion, or other forms of negotiation, such bracelets or stickers indicating HIV status (Grov et al., 2014a). Serosorting can be ineffective if some MSM wrongly think they are HIV negative or incorrectly assume the serostatus of a potential partner by physical appearance or sexual positioning as top or bottom (Marcus, Schmidt, & Hamouda, 2011; Velter et al., 2013). Serosorting may have contributed to rising rates of hepatitis C (HCV) in some locales through an increase in CAS (Jin et al., 2010); however, HCV is also linked to sharing implements for nasally administered recreational drugs or “rough sexual techniques” such as fisting that can transfer blood (Matser et al., 2013; Urbanus et al., 2009). Pre-exposure prophylaxis (PrEP) is also increasing among HIV-negative MSM. Some researchers express concern about risk compensation with PrEP, such as the abandonment of condoms, that could increase the spread of other STIs (Alaei, Paynter, Juan, & Alaei, 2016; Kalichman et al., 2017), although others suggest that existing risk reduction strategies continue alongside PrEP (Grov, Whitfield, Rendina, Ventuneac, & Parsons, 2015; Hojilla et al., 2016).

Given risk reduction practices, HIV/STI risk should not be viewed as an inherent consequence of sex with casual, multiple, or concurrent partners, but instead as “a consequence of such behavior in conjunction with failing to practice safe sex” with an infected partner (Giles, 2006; Prestage et al., 2009b).

Onsite Sexual Risk-Taking

Studies of MSM vary in definitions of risk behavior, venue classification, sampling strategies, and data collected. Masturbation and oral sex are reported more frequently than anal sex or other anal behaviors onsite in PSEs across geographic locales (Frankis & Flowers, 2005, 2009) and SOPVs. Across environments, onsite CAS (or a comparable anal risk behavior) during last or recent visit occurs among a minority of participants: for example, 7–8% in bathhouses, Bingham et al. (2008); 13.9% in bathhouses, Binson, Pollock, Blair, and Woods (2010); 23.7% in public/commercial sex venues, Downing and Hirshfield (2015); around 30% across threesomes, “organized,” and “spontaneous” sex parties, Grov et al. (2013b); 10% in PSEs, Frankis and Flowers (2005); 22% at bathhouses, Ko et al. (2006); less than 15% in SOPVs (Lyons, Smith, Grierson, & von Doussa, 2010); 25% at sex parties, Mimiaga et al. (2010); 32.5% at GSE, Prestage et al. (2009c); 13.2% in bathhouses, Reidy et al. (2009); 14% in “public” settings, Reisen et al. (2010); and 11% at bathhouses, Woods et al. (2007). Higher rates of CAS are reported among HIV+ MSM and those identifying as “barebackers” (Frankis & Flowers, 2006; Mimiaga et al., 2011; Prestage et al., 2009b).

Sexual risk-taking in collective sex environments appears influenced by structural factors (such as privacy and safety) and psychosocial factors (such as a lack of love, trust, or intimacy) (Frankis & Flowers, 2006). UAI/CAS has been found more common in private homes when compared with PSEs (Frankis & Flowers, 2005) or SOPVs (Reisen et al., 2010; Rusow, Fletcher, & Reback, 2017; Woods et al., 2007). Phang et al. (2008) note that although UAI was reported onsite among MSM attending SOPVs (8.5%), the frequency of UAI and other anal behavior “was actually higher with casual male partners outside of these venues.” Reisen et al. (2010) tested within-person differences in sexual behaviors in public and private settings, finding that anal sexual behavior was most likely in CSVs such as bathhouses, which are designed for sexual encounters, and least likely in PSEs; however, more UAI and anal sexual behavior took place in private homes or hotels.

Across collective sex environments, condom use and the use of other risk reduction strategies, such as withdrawing before ejaculation, is also higher than in private settings (Frankis & Flowers, 2006; Marcus, an der Heiden, Gassowski, Kruspe, & Drewes, 2015; van den Boom et al., 2016). For example, although Rusow et al. (2017) argue that HIV transmission risk was higher in CSVs and PSEs than in private locations due to anonymous partners, potentially serodiscordant sex, and drug use during sex, they found that when anal sex did occur, venues were associated with less CAS and more condom use. van den Boom et al. (2016) found men more likely to use condoms during group sex than dyadic sex; still, although “group sex may not necessarily be risky for HIV infection compared with dyadic sex,” a GSE could be a higher-risk setting for acquiring other STIs, such as gonorrhea (although they admit that the gonorrhea cases observed could have been transmitted through dyadic encounters).

Some research has associated GSEs with serodiscordant UAI, with diagnosed and/or undiagnosed HIV+ participants, or onsite drug use (Hirshfield et al., 2015; Mimiaga et al., 2011; Phillips, Grov, & Mustanski, 2015; Phillips et al., 2014; Prestage et al., 2009b). However, as attendees can self-select for events relevant to sexual health or drug use, GSEs vary in terms of onsite transmission risks (Bourne, Reid, Hickson, Torres-Rueda, & Weatherburn, 2015; Reisner et al., 2009). Of participants engaging in UAI with a serodiscordant or HIV unknown status partner at the last sex party attended, 50–75% self-identified as ‘‘barebackers,” depending on the study (Mimiaga et al., 2010, 2011). HIV+ men, including barebackers, sometimes select HIV+ partners (Pollock & Halkitis, 2009).

The literature on MF collective sex is sparse, and although onsite risk behavior varies, it also occurs among a minority. In a sample of young adults, injection drug users, and other “high-risk” populations, Friedman et al. (2008) found that 13% of respondents who had attended a GSE in 12 months prior (n = 167/465) had unsafe sex at the event (2008: 444). Among self-identified swingers recruited online, Platteau, van Lankveld, Ooms, and Florence (2017) found “inconsistent” condom use during swinging for vaginal (43% of men/33% of women) and anal (12.5% of men; 14% of women) sex, and Kimberly and Hans (2017) report that 20% of their 34 respondents “preferred not to use condoms,” 50% used condoms sporadically, and one-third required condoms during swinging (795). Unfortunately, and in contrast to the MSM literature, some swinging research does not adequately account for safer sex strategies. For example, Spauwen, Neikamp, Hoebe, and Dukers-Muijrers (2015) report that over half of the self-identified swingers they surveyed had had group sex in the previous 6 months, and “half of them did not use condoms during group sex” (32); however, they do not distinguish between primary and other partners. Qualitative research suggests that condom use for vaginal or anal sex with non-primary partners is normative in mainstream swinging environments in the USA, Finland, Norway, and other locales, especially among younger participants; when condomless sex with casual partners occurs, it is more likely in private homes (Bentzen & Træen, 2014; Frank, 2008; Harviainen & Frank, 2016). Further, few MF overall use condoms for oral sex, yet this is sometimes counted as risk behavior at swingers’ clubs (see O’Byrne & Watts, 2011; Platteau et al., 2017).

Venue-Specific Characteristics

Studies of patron demographic and psychosocial characteristics have found different risk profiles among MSM recruited for research from different collective sex environments (Grov, 2012; Grov, Rendina, & Parsons, 2014c; Reisner et al., 2009) and depending on the venue where they most frequently or recently find sexual partners (Grov, Rendina, Ventuneac, & Parsons, 2014d; Xia et al., 2006). Studies comparing MSM recruited from different environments, such as a sex club, craigslist, or a park, can ensure coverage of each type of location of interest; however, this design also categorizes a respondent recruited from a PSE as a PSE user even if he patronizes other environments more frequently or finds more sex partners elsewhere. Other studies recruit MSM more generally and instead compare groups based on the environments they most recently or frequently find sex partners (such as through dating apps, at sex environments, and public places). However, as such samples are often drawn from online populations, they may lead to class or other biases.

To more clearly understand how the location of sex influences onsite risk-taking behavior, researchers have thus explored how patterns of sociality and sexuality vary with physical and social context. Sexual cultures theory posits that local sexual culture influences negotiations, behaviors, and the meanings of sexual interactions, thus shaping health risk profiles (Frankis & Flowers, 2009). Person–environment and ecological psychology theories explore the relationship between the structural and atmospheric characteristics of a setting, whether natural or man-made—architectural layout and design, lighting, sound, alcohol availability and use, relations between patrons and staff, the availability of water, condoms, lubricant, and safer sex information, perceptions of other users, etc.—and participants’ behavior. Site-specific norms such as those surrounding communication and condom use further combine with these factors to “set the stage” for onsite behavior (Balán, Barreda, Marone, Ávila, & Carballo-Diéguez, 2014; Downing Jr & Hirshfield, 2015; Grov, Hirshfield, Remien, Humberstone, & Chiasson, 2013a; van den Boom et al., 2015).

In SOPVs, more explicit or transgressive sexual activity is most likely in places with the least visibility, such as maze and steam rooms, saunas, and darkrooms (Ko et al., 2008), or areas with low lighting or private rooms (Holmes, O’Byrne, & Gastaldo, 2007; Reidy et al., 2009). Across venue types—bars/dance clubs, sex clubs, and porn theaters—Balán et al. (2014) report that anal intercourse “appeared to occur primarily in spaces where some privacy was perceived” such as dark rooms, bathroom stalls, video booths, or places with low lighting. Downing and Hirshfield (2015) found that CAS at a gym or video booth was related to perceived greater availability of private spaces and to low lighting in a public park (335). In restrooms, Brown (2008) noted that group sexual activity and anal penetration occurred in the back of the building where men who were watching could shield the performers with their bodies; similarly, in monitored bathhouses, Woods, Sheon, Morris, and Binson (2013) observed patrons hiding each other from the view of staff during barebacking. A comparison of venues in Seattle, WA, found that men engaged in more UAI at bathhouses than a sex club, because the sex club offered no private spaces, while the bathhouses featured private rooms with horizontal surfaces, showers, towels, and regular nudity (Reidy et al., 2009). Venues that do not offer relatively private space may also attract a more exhibitionist clientele (Woods et al., 2007).

Norms of silence in PSEs or bathhouses arguably impede discussions of sexual health and condom use (Woods et al., 2007). PSEs are associated with the lowest levels of serostatus disclosure (Marcus et al., 2015). Not all studies have found a lack of communication among MSM using collective sex environments, however; Grov et al. (2013a) found that HIV status disclosure was relatively high among men who met their most recent sex partner online or at a bathhouse. Disclosure of HIV status may be easier in environments allowing for relative privacy and increased socialization before sex, or online prior to meeting; however, prior serostatus disclosure can also lead to a decrease in condom use (Marcus et al., 2015).

Site specificity aids in developing interventions. Outreach workers can remain low profile in PSEs, adapting their strategies to fit each unique landscape. Bathhouses and sex clubs can openly display safe sex messages, offer educational materials, and provide condoms in appropriate places on premises (Ko et al., 2008; Woods et al., 2010). However, the precise direction of environmental influence remains debated: Do certain venue-specific or structural characteristics inevitably lead to riskier behavior or are patrons drawn to environments where they can engage in sexual activities that they are already seeking due to personality/motivational characteristics? (Grov, 2012; Reisner et al., 2009: 817). Some researchers suggest modifying the structural or atmospheric elements of SOPVs to promote safer sex—turning up lighting or eradicating the relatively private areas where riskier sex occurs (Balán et al., 2014)—while other researchers argue that altering these spaces would displace risky behavior rather than prevent it (Reidy et al., 2009; Richters, 2007; Woods et al., 2010).

Limitations and Complications

Comparisons of the demographics, characteristics, and sexual risk profiles of people sampled from, or finding partners in, different types of venues are complicated. Evidence indicates that the minority of individuals engaging in risk behaviors in collective sex environments also engage in risk behaviors elsewhere and in dyadic sex (Bingham et al., 2008; Kerr, Pollack, Woods, Blair, & Binson, 2015; Mimiaga et al., 2010; Phang et al., 2008; Prestage, Down, Grulich, & Zablotska, 2011; Reidy et al., 2009; Wei, Lim, Guadamuz, & Koe, 2014; Whittier, Lawrence, & Seeley, 2005; Woods et al., 2007; Zablotska et al., 2014). Many MSM also frequent and find sex partners in multiple venues regardless of where they are recruited for research (Aynalem et al., 2006; Daskalakis et al., 2009; Downing, 2012; Downing & Hirshfield, 2015; Grov, 2012; Grov et al., 2014c; Pollock & Halkitis, 2009; Reidy et al., 2009; Wei et al., 2014). Grov, Parsons, and Bimbi (2007) found that “identity as a barebacker and temptation for unsafe sex” better explained UAI than the venues where MSM met their sex partners. A review of 138 studies of within-person risk-taking suggests that associations between attendance at SOPVs and person-level sexual risk (UAI/PAI) may be due to an overall propensity toward or preference for unprotected sex in general, without specific location effects. Two reviewed studies showed significant positive associations of sero-nonconcordant UAI with non-private settings, suggesting that location factors were involved, but the authors argue that this could be due to situational differences in risk appraisal, such as “the ability to make informed decisions about the seroconcordance of partners with whom to engage in UAI,” rather than the decision itself to engage in UAI (Melendez-Torres et al., 2016).

Environments within the same category differ, making generalizing based on venue type difficult (Binson, Pollack, Blair, & Woods, 2010) and leading to conflicting findings. Variation may result from local regulations requiring behavioral monitoring in bathhouses and sex clubs, and individual site policies and enforcement (Woods et al., 2013); for example, some SOPVs have been associated with onsite substance use, while others have not (Grov & Crow, 2012). Variation in risk profiles between and within venues can arise from the self-segregation of users or participant inequalities related to social class, race, age, educational attainment, etc.—for example, poverty or housing instability in some urban areas can affect the use of nearby PSEs, and marginalized individuals may take risks for economic reasons (Rusow et al., 2017). GSEs vary in terms of social organization (“spontaneous” vs. “organized”; private vs. commercial), theme, size, substance use, access, etc. (Grov et al., 2013b; Mimiaga et al., 2010). Even research using the same method in the same city during the same time period can reveal differences between venues in the same category. Balán et al.’s (2014) ethnographic observations in six paired venues in Buenos Aires—two porn theaters, two sex clubs, and two dance clubs—revealed important differences in patron socializing, alcohol consumption, sexual behavior, and the availability of HIV prevention materials between each pair of venues, not just between venue types.

Further, sex-seeking is dynamic. Political, legal, economic, technological, and social changes influence user demographics and sociosexual behavior patterns (Richters, 2007; Xia et al., 2006). Over 40 years ago, Humphreys (1975) found that many men having sex in public restrooms did not identify as gay or bisexual; studies from the early 2000s found mostly gay-identified men in PSEs and bathhouses (Huber & Kleinplatz, 2002; Mutchler et al., 2003). More recently, Rusow et al. (2017) found more white, gay-identified MSM at CSVs and more minority, non-gay-identified MSM at PSEs; however, housing instability, racial/ethnic and sexual identity, and other socioenvironmental factors influenced venue selection. Local regulations mean that type of venue and sexual practice are interrelated, but not straightforwardly so. Group sex, for example, has been reported more frequently in bathhouses, sex clubs, or at private parties, depending on the decade and locale (Helquist, 2003; Hirshfield et al., 2015; Meunier, 2014; Sowell, Lindsay, & Spicer, 1998). This is not due to any inherent characteristics of group sex or of these venues, but to an evolving social and legal context. Sexual landscapes also transform with technological advances offering safety and convenience, such as the Internet or mobile technology (McGlotten, 2014; Melendez-Torres et al., 2016). Studies reporting differences between people finding sexual partners “online” versus other realms are rapidly becoming irrelevant in an age of widespread Internet dating, social networking, and mobile technology. Craigslist was once revolutionary for facilitating “casual encounters” between MSM and MF strangers, but the composition of users has already shifted with the introduction of GPS-based mobile applications.

Even the STIs of concern change over time, as infections disappear or remerge and as diagnostic and treatment possibilities are refined. Global mobility and networking facilitates the spread of once localized strains of infection, antimicrobial resistant bacteria, and new viruses such as Zika (Lee, Sullivan, & Baral, 2017; Solomon & Mayer, 2015). PrEP or TasP (treatment as prevention) is now suggested to accompany or replace behavioral interventions among conscious sexual risk-takers (Chen et al., 2013; Hirshfield et al., 2015; Prestage et al., 2015; Velter et al., 2013; Wells, Golub, & Parsons, 2011; Zablotska et al., 2014). Yet, even as PrEP potentially decreases HIV transmissions, it also changes sexual practices and the transmission rates of other STIs (Scott & Klausner, 2016).

High-Risk Groups, Subcultures, and Networks

Regardless of whether, or how much, risky sexual behavior occurs onsite across venue types, the use of collective sex environments has been associated with “high-risk” groups, subcultures, or networks. Between-person differences have been found among MSM who use PSEs, CSVs, or attend GSEs/sex parties and MSM who do not, with collective sex participants more likely to have more sex partners, have more anonymous, casual, and/or multiple sex partners, engage in UAI (though not necessarily on site), have undiagnosed HIV or STIs, or be diagnosed HIV-positive (Aynalem et al., 2006; Gama et al., 2017; Grov et al., 2014b; Hirshfield et al., 2015; Pedrana, Hellard, Wilson, Guy, & Stoové, 2012; Phillips et al., 2015; Rice et al., 2016a). Collective sex among MSM has been correlated with individual-level characteristics such as sensation-seeking or sexual compulsivity (Grov et al., 2007; Mimiaga et al., 2011; Vu et al., 2016), and linked to syndemics, or synchronous epidemics that are culturally produced through marginalization, such as substance use, childhood sexual abuse, depression, and partner violence (Hirshfield et al., 2015; Solomon et al., 2011).

The use of collective sex environments has also been associated with other behaviors linked to sexual risk-taking, such as drug use, though the behaviors do not necessarily occur simultaneously (Friedman et al., 2017; Prestage et al., 2007; Spauwen et al., 2015; Zhao et al., 2017). Gay men have higher rates of illicit drug use than heterosexual men, but for both MSM and MF, meth or stimulant use has been used as a proxy marker for individuals engaged in sexual activities considered high risk (Aynalem et al., 2006; Carey et al., 2009; Zule et al., 2007). In samples recruited across venue types (although not in every venue), researchers repeatedly identify minority groups in their samples reporting not only sexual risk-taking (defined in heterogeneous ways across studies) but also substance use (Chen et al., 2015; Grov et al., 2014c; Hirshfield et al., 2015; Mimiaga et al., 2010; Phillips et al., 2014; Prestage et al., 2011; Velter et al., 2013) or other behaviors defined as risky, such as trading sex for money or drugs (Friedman et al., 2008; Zule et al., 2007). Similar to the percentages of onsite risk-taking, the percentage of these multi-risk-takers tends to range from 10 to 25% across studies.

Collective sexuality is part of the definition of “sexual adventurism,” which involves tendencies toward statistically linked sexual behaviors: high number of partners, high sexual frequency and duration, UAI, “esoteric” sex practices (BDSM, fisting, anal fingering or rimming, the use of sex toys), group sex, and the use of sex clubs (Hurley & Prestage, 2009; Prestage et al., 2007). The literature often associates sexual adventurism with gay-identified men that have strong connections with gay community venues (Bradshaw et al., 2016; Prestage et al., 2015; Velter et al., 2013; Zablotska et al., 2014). In some analyses, these linked behaviors are used as a key indicator of participation in “sexually adventurous subcultures” associated with HIV/STIs, sexual risk-taking, illicit drug use, and other psychosocial issues (Cheung, Lim, Guadamuz, Koe, & Wei, 2015; Prestage et al., 2007; Prestage, Grierson, Bradley, Hurley, & Hudson, 2009a; Prestage et al., 2011). Sexually adventurous subcultures are occasionally noted among MF (Buttram & Kurtz, 2015; Friedman et al., 2017; Spauwen et al., 2015) and WSW (Albury, 2015), although without the HIV burden.

In addition to being indicated by clustered behaviors, subcultural participation is sometimes assessed through respondents’ self-identification, or through identification of their social connections. Matser et al. (2013) found that HIV+ men that self-typed as belonging to “leather” or “jeans” subcultures in Amsterdam were more likely to be HCV-seropositive and to engage in high-risk sexual behavior than men who did not identify with those subcultures; however, many MSM reported belonging to more than one subculture and there was no clustering of HCV strains among the subcultures. Prestage et al. (2015) identified five subcultural groupings among GBM in Australia (sexually adventurous; bear tribes; alternative queer; party scene; and sexually conservative). Higher scores on the Sexually Adventurous measure were associated with being older, HIV-positive, less likely to have university education, having more gay friends, and having more sex partners; CLAIC was associated with higher scores on both the Sexually Adventurous and Bear Tribes measures. The Sexually Adventurous grouping—men who indicated involvement with this subculture and described their friends similarly—appeared to be a highly sexually active network where interactions occurred in a context of high HIV prevalence, making transmission risks high. However, 62.5% of the respondents overall reported some connection with the Sexually Adventurous grouping, individuals’ engagement with subcultures appeared fluid and overlapping over the life course rather than discrete. Other research has similarly suggested that individuals have multiple, fluid, and overlapping memberships in “scenes” (such as BDSM-Bear-Leather, Party and Play, Dance Club) (Noor et al., 2018) or in terms of categorizations or attributions (“types” such as married men, leather men, sex pigs, or young men) (Smith, Grierson, & von Doussa, 2010) that become associated with different risk profiles.

Network studies have proven useful for understanding actual STI outbreaks in various locales (D’Angelo-Scott, Cutler, Friedman, Hendriks, & Jolly, 2015) and ideally account for the presence and type of STI infection as well as the structure of network connections. People may engage in similar risk behaviors—sexual or otherwise—but never become infected since HIV or other STIs are “not present or not present to a great extent in their social or sexual networks.” HRH, for example, have low HIV prevalence even when they have more risk factors for infection than MSM or injecting drug users, including engaging in sexual behaviors such as UI, group sex, or drug use (Friedman et al., 2017; Raymond, Ick, & Chen, 2016).

Collective sex environments have been considered “risk environments” due to sexual and social network features. Sexual networks influence STI risk through concurrency, “bridging,” and/or “mixing” involving high-risk groups. Concurrency is considered higher risk than serial monogamy for some types of infections, even if the total number of partners is equivalent (Wohlfeiler & Potterat, 2005: S49). Bridging occurs when core individuals move between groups that are dissimilar in the prevalence of infection, as when traveling (Apostolopoulos et al., 2011; Zablotska et al., 2014). Dissortative mixing occurs when high- and low-risk groups interact, such as those that are STI discordant or drug users/non-drug users. Bridging is usually more important in the introduction of an infection into the population and mixing more important in its spread, although this depends on the characteristics of the STI in question (Aral, 2002). Collective sex environments also generate social networks, which influence STI risk by establishing “microenvironments” where people interact and develop “shared behavioral norms and risk behavioral characteristics” (Amirkhanian, 2014). Although social networks sometimes overlap with sexual networks, they should not be conflated.

Limitations: Full Circle?

The identification of high-risk groups, subcultures, and networks is meant to counter the homogenization occurring when groups are considered high-risk without contextualization of their leisure and sexual practices. As experts call for prevention efforts “more narrowly focused toward those who are truly at risk for HIV” (Kerr et al., 2015: 443), the hunt continues for the most at-risk, high-risk groups: Who are the riskiest risk-takers of them all? Where are they, and how might we intervene? Collective sex environments become spaces where such populations can be identified, studied, and targeted for education, behavioral interventions, and STI testing.

Ultimately, however, as a theoretical or research agenda, the classification of groups “at risk for risk-taking” itself becomes homogenizing. Smaller and smaller subsets of individuals are identified, but at some point, one is forced to grapple with differences between members of the same risk group—or create a new one. Classifying GSE attendees as high-risk, for example, overlooks differences between bareback, “chemsex,” and “safe sex” parties, but also between participants at each event, some of whom engage in sexual behavior that puts them at risk of HIV/STIs and some of whom do not (Batrouney, 2009; Bourne et al., 2015; Grov et al., 2014b; Reisner et al., 2009; Solomon et al., 2011). Lifetime and recent GSE participation among MSM recruited online (88%, Grov et al., 2013b; 68.5% lifetime, 45% past year, Grovet al., 2014b) is higher than among MF recruited online (< 8% lifetime, 2% past year, Herbenick et al., 2017). Yet participants are far from uniform in sexual behavior. Although Phillips et al. (2014) report that 32% of the GSE participants in their sample did not use condoms with any partners at their last event, 47% used condoms with all their sex partners and 75% changed condoms between partners; 21.7% used condoms with some of their anal sex partners, which could indicate that they were distinguishing regular and casual partners or serosorting. Calls for more research are ubiquitous, and ever finer distinctions appear in the literature, such as between the risk profiles of individuals engaging in threesomes, “spontaneous,” or “organized” group sex (Grov et al., 2013b), or between MSM having group sex with 4 or more partners, group sex with 2 or 3 partners, or only reporting one-on-one partners (Hirshfield et al., 2015). Parsing out such differences may be useful for health professionals evaluating candidates for PrEP. However, such distinctions may obscure more than they illuminate when assessing the risk of collective sexuality in other populations.

Similarly, some network analyses unfortunately rely on subjective assignments of network positions based on assumed cultural or behavioral characteristics: for example, truck drivers are defined as “bridges,” regardless of STI status, risk-taking, or health protective behavior (Shah et al., 2014; Lichtenstein, Hook, Grimley, St. Lawrence, & Bachmann, 2008). In addition, theoretical projections of how an STI might spread throughout a network can be disrupted by actual sexual behaviors, such as the dyadic onsite partnering patterns observed among men in bathhouses (Binson et al., 2010). Differential access to health care also means that less privileged groups may experience longer duration of infection even with treatable STIs (Aral, 2002), which has implications for concurrency risks. Dire predictions based on hypothetical infections or assumptions that social and sexual networks overlap—such as that swingers “may act as an STI transmission bridge to the entire population” (Dukers-Muijrers, Niekamp, Brouwers, & Hoebe, 2010)—fall flat if individuals are not actually sexually “bridging,” engage in risk reduction behavior, or receive prompt treatment for bacterial STIs.

Section II: An Inclusive Perspective on the Social Organization of Collective Sex: Insights from Ethnographic, Qualitative, and Observational Research

When examined inclusively, the hundreds of detailed studies on collective sex environments in existence—ranging across more than 50 years—make some generalizations possible despite the dynamic and complex nature of sex-seeking. As transgressive spaces, collective sex environments develop some similar organizational features due to participants’ needs for physical, social, and psychological safety. These include: (1) a segmentation of space and time for social and sexual purposes allowing for progressively more explicit, transgressive, or vulnerable interactions, and (2) social norms focused on ascertaining the intentions and consent of potential participants. This section briefly details these patterns of spatial and social organization, followed by a discussion of the implications of an inclusive analysis for our understanding of risk in Section III.

A few publications have examined similarities across sites, or across types of collective sex environments. Frankis and Flowers (2009) reviewed 14 pre- and post-epidemic qualitative studies on PSEs, arguing that the remarkable similarities emerging “across analytical approaches, methods, decades, countries, and PSE types” is “evidence of a coherent sexual culture of PSEs,” “driven by the shared importance of covert sexual negotiation and subversion of environmental features.” Nonverbal communication is prioritized as cruisers seek sexual partners while attempting to avoid physical and social hazards—discovery, violence, arrest, etc.—and oral sex and mutual masturbation are the “mainstay of PSE sexual culture” (2009: 881). A recognizable spatial and social organization thus develops, even as locations also vary in geographical features, structural facilities, climate, risk of police harassment or homophobic violence (Frankis & Flowers, 2009; Flowers, Marriott, & Hart, 2000). Bathhouses also exhibit similarities to each other in spatial organization and behavioral expectations and to other types of collective sex environments (Green, Follert, Osterlund, & Paquin, 2010; Huber & Kleinplatz, 2002; Tewksbury, 2002; Van Lieshout, 1995; Weinberg & Falk, 1980; Weinberg & Williams, 1975; Woods & Binson, 2003). Such a comparison can be extended across additional environments—PSEs, bathhouses, sex clubs, BDSM clubs, private sex parties, and so on—and across patron sexualities (Frank, 2013).

Social and Sexual Zones: The Importance of Spatial Segmentation and Progression

The spatial organization of collective sex environments reflects an underlying tension between access and the management of exposure. The segmentation of space into social/exploratory and sexual zones serves a gatekeeping function, protecting against accidental or hostile intruders and allowing participants to manage exposure as their behavior becomes more transgressive. The importance of spatial segmentation and progression remains even if there is little immediate legal or physical danger, as it also allows participants to evaluate potential partners and negotiate sexual activity.

In indoor or outdoor PSEs, the potential presence of visitors who are not seeking sex means that “exposed, peripheral areas” require greater subtlety,” and are used for cruising and socializing, while more sheltered or internal areas—behind bushes, a cave on a beach, back rooms in nightclubs, etc.—allow for more explicit negotiations and sex acts (Anderson, 2017; Andriotis, 2010; Frankis & Flowers, 2009: 884; Kelly & Muñoz-Laboy, 2005). In San Jose Park in New York City, sex seekers cruised the dirt trails rather than the paved paths patrolled by park rangers, utilizing hills and steps as vantage points to spot either potential partners or intruders. The main sex spot was “a small cove at the bottom of a ravine hidden under a complete cover of a thick tree canopy and dense bushes” where an uprooted tree provided support during sexual activity (Kelly & Muñoz-Laboy, 2005). In public restrooms, communal areas can be observed to determine who is pursuing sex, while bathroom stalls are used for sexual activity. As the possibility of spatial progression is minimal in a restroom, gatekeeping functions can also be performed through code words or sounds (“sniffs or coughs”), nonverbal signals (foot tapping; gesturing), roles (“lookout”), or modifying behavior in the presence of suspicious individuals (Anderson, 2017; Humphreys, 1975). For “doggers” or “truckchasers (MSM who find partners at truck stops),” the inside of vehicles becomes a sexual zone (Apostolopoulos et al., 2011; Corzine & Kirby, 1977). The backrooms of adult bookstores and gay clubs require movement through non-sexual space and incremental access to sexual zones; similarly, in health clubs or gyms, saunas and showers with curtains can serve as sexual zones but require participants to have already accessed the main areas of the club (Leap, 1999).

SOPVs vary in layout and amenities, but in each venue, spaces overwhelmingly become segmented into social or sexual. Gatekeeping is partially handled at the entrances (Tattelman, 1999; Tewksbury, 2008) and can serve multiple functions, such as refusing entry to suspicious individuals or cultivating a particular level of attractiveness among guests (Frank, 2008; Green, 2011). At some venues, patrons undergo screening at a reception area, provide identification, or sign waivers acknowledging that they might view sexual activity, making it difficult for undercover police to argue that they involuntarily witnessed lewd conduct (Craig, 2009). Gatekeeping can also be handled by tightly controlling access, as at venues or events where guests are pre-screened by hosts (Frank, 2007). Once inside, progression is again required through spaces used for socializing or evaluating potential partners to those where more explicit sexual activity occurs. Social zones are generally those areas with “the brightest lights,” the most “open space, and where the most clothing is worn, such as at the entrance to a facility—the atmosphere signals that sex is deviant in these areas” (Tewksbury, 2002: 91). Progression from social into sexual zones may require navigating corridors, stairs, and so on (Brodsky, 1993; Hammers, 2009) and be accompanied by atmospheric changes such as dimmer lighting and louder music that stimulate senses other than the visual and provide for psychological transition (Haubrich et al., 2004; Prior & Cusack, 2009). Reception areas, TV or snack rooms, and hallways tend to be non-sexual, while communal, semiprivate spaces such as a steam room are occasionally used for sex; sex most frequently occurs in private rooms or cubicles and other specialized areas (Richters, 2007; Tewksbury, 2002). Some venues create special sections for voyeurism and exhibitionism or that mimic the spatial organization of other environments, such as glory holes, mazes, gyms, or prison cells. In any venue, however, one will rarely be immediately exposed to the most explicit sexual areas (“dark rooms”; dungeons for BDSM play; orgy rooms; slings for fisting).

Of course, additional considerations also influence sexual behavior in any given setting—ease of nudity, exposure to the elements, horizontal space, the availability of water for washing, crowd density, performances, and so on. Nonetheless, a desire to manage exposure through either visibility or access when engaging in transgressive behavior operates across collective sex environments and maps onto the findings discussed in Section I on the impact of structural and atmospheric features on sexual practices. Management of exposure is also sought for activities that are stigmatized in any given context. In the U.S., lifestyle events where male same-sex behavior occurs have more barriers to entry than mainstream events, such as a referral system (Harviainen & Frank, 2016). BDSM practitioners who do not follow mainstream safety protocols and prefer “edgeplay” may prefer private homes to clubs (Newmahr, 2011). Non-disclosing men who have sex with men and women (MSMW) or MSM who believe that being the receptive partner is less masculine seek relative privacy for encounters (Richters, 2007; Schrimshaw, Downing, & Siegel, 2013). Given that safe sex protocols are normative in many collective sex environments, condomless sex can become transgressive even when not explicitly prohibited—and thus also potentially eroticized, stigmatized, and less visible than other encounters (Ávila, 2015; Jenks, 1998; Villaamil & Jociles, 2011).

Borders between zones may blur depending on the needs of participants, their familiarity with each other, or geographic idiosyncrasies. Qian (2014) describes a section of People’s Park in Guangzhou, China, where lower-income gay men cruise along three corridors. Even though sex occurs in secluded restrooms or off-site, the fact that many straight park users recognize the “gay belt” as a cruising spot sparks both feelings of community and anxieties about being perceived as “abnormal” in cruisers. Without the possibility of gatekeeping through architectural features, limiting access, or concealing intentions, cruisers are thus careful not to flaunt their deviance through actions or appearance, and go out of their way to interact with straight park users in legitimate leisure activities, such as public dancing, elsewhere in the park. Some hotels have layouts and amenities that are conducive to the needs of collective sex participants, such as suites with separate living and bedroom areas, rooms that can be accessed without using keycards in the elevators, discrete entrances, or favorable acoustics. Yet even in a basic hotel room, spatial segmentation arises; one may find guests conversing near the door or bathroom, while sexual activity unfolds on the bed, for example. Private parties reflect similar organization, depending on the layout of the venue, and guests who do not use space appropriately may be reprimanded (Frank, 2013; Meunier, 2014; Mimiaga et al., 2011). Meunier (2014) describes a sex party held in one large room: casual conversations occurred in the lobby or changing areas, and only rarely in the play space, where nudity was required and talk was minimized. When spatial features cannot be manipulated, other strategies can be used to progress from social to sexual behavior: requiring nudity or locking the doors after a certain time in the evening, flicking or dimming the lights to mark an end to socializing, or encouraging “ice breaker” games to remove clothing or initiate contact (Cooper, 2009; Varni, 1972).

Social Norms Organizing Behavior and Interaction

Patterns of spatial segmentation and progression are ubiquitous and similar across collective sex environments, but context-specific norms and expectations also emerge to organize social interaction (the discussion here focuses on behavioral norms that can be observed, although emotional norms also exist, such the norm that recreational sex among swingers should not develop into passionate love). The use of the term “play” to refer to sex is frequent across recreational sexual enclaves, indicating both an expansion of the customary link between sex and love and suggesting rules of engagement (Race, 2015; Weiss, 2006). Some environments are centrally organized with explicit, formal rules, as in many SOPVs, bathhouses, lifestyle, or BDSM venues (Hammers, 2009; Harviainen, 2015; Villaamil & Jociles, 2011). Other environments, such as PSEs or unorganized sex parties, involve implicit expectations (Apostolopoulos et al., 2011; Friedman et al., 2011; Pryce, 1996; Ravenscroft & Gilchrist, 2009). Still, in any environment, some behavior—social or sexual—is expected or encouraged, while other behavior is discouraged or prohibited. At lifestyle parties, couples rarely engage in BDSM even if they are also practitioners; at BDSM parties, it is rare to see sexual intercourse (Moser, 1998). In the U.S., same-sex female behavior is common at mainstream lifestyle events, while same-sex male behavior is disruptive; in Finland, however, male–male sexual encounters are relatively unproblematic in lifestyle settings (Harviainen & Frank, 2016). Male sex party participants describe events where condom use is so pervasive and expected as to be “ritualistic,” events where the tacit agreement is not to even mention condoms or sexual health, and still other events where condom use was negotiated verbally or nonverbally onsite (Meunier, 2017).

Context-specific norms vary, but are overwhelmingly concerned with intention and consent. In PSEs, direct conversation risks “outing” oneself to someone who is not seeking sex; sex seekers “test” potential partners for signs of interest or danger using nonverbal behavior or coded language (Brown, 2008; Frankis & Flowers, 2009). Delph (1981) suggested that enlisting public sex participants to warn each other about off-limits areas in public libraries would be more effective than entrapment or other methods, as participants acquire a “common language” even if they are strangers and their behavior is loosely organized. Some Latino MSM immigrants in New York City preferred PSEs or PSVs to bars because they could arrange sexual encounters without being fluent in English (Bianchi et al., 2007).

Tewksbury (1996) identifies five modes of nonverbal communication used in cruising to determine intent and express sexual interest—eye contact, use of personal space, body language (suggestive movements or gestures), subtle forms of touching (oneself and others), and movement (pursuit, display, and positioning). Even in settings where access is controlled enough that sexual intentions can be assumed, however, participants must still ascertain whether a specific advance is welcome; thus, these nonverbal behaviors are found across collective sex environments. Eye contact, the use of personal space, body language, and subtle touch arise in everyday flirtatious exchanges, and sex seekers are already somewhat familiar with interpreting these signals. Sexualized touch and display indicate interest in some environments, as participants adjust their advances and reactions to the setting. In all-male environments, men might display an erection, masturbate, or intimately touch a potential partner to initiate sexual activity (Andriotis, 2010; Weinberg & Williams, 1975). Advances can be refused by avoiding eye contact, moving away, or verbally expressing disinterest, usually “without hard feelings”; men who respond “prudishly” might be mocked or avoided, however (Meunier, 2014: 689). In many MF environments, however, intimate touching before verbal negotiation would likely be interpreted as aggressive by both men and women; touch is more likely to be accepted if initiated by a woman or on a clothed or non-sexual body part (Bentzen & Træen, 2014; Frank, 2008).

Pursuit, display, and positioning can also express intent and interest. Pursuit may involve following potential partners through a park, bathhouse, or other venue; the length of the “chase” varies depending on each partner’s interest, type of environment, and the perceived risks involved (Brown, 2008; Tewksbury, 1996). In lifestyle environments, people interested in joining an ongoing scene position themselves nearby and attempt eye contact; couples only interested in voyeurism avoid eye contact and distance themselves from the sexual activity. In an adult theater, Douglas and Tewksbury (2008) found that men who wished to masturbate alone stood at the front of the theater, those who sought partners masturbated in the middle sections, and men who sought oral sex leaned over the rear row of seats facing the screen, genitals exposed. In bathhouses or sex clubs, doorways to private rooms may be left ajar during sexual activity as an invitation to enter or watch; if horizontal surfaces are available, waiting MSM who are receptive to anal sex might lie on their stomachs while inserters lie on their backs (Mutchler et al., 2003). Glory holes, where only genitals are visible, exemplify sex organized primarily by positioning (Bapst, 2001; Holmes, O’Byrne, & Murray, 2010).

Verbal negotiation differs across collective sex environments and sexualities. Preliminary negotiations for sexual activity can be conducted online such that less discussion is necessary onsite: party hosts select attendees to coordinate social and sexual aims; lifestyle couples set limits by identifying as “full swap,” “soft swap,” or “girl–girl only” in web profiles (Griffiths & Frobish, 2013); MSM exchange information about viral load through online chat (Race, 2015). Onsite, even if talking is permitted in social zones, it is less acceptable in sexual zones. Environments catering to MSM range from being characterized by a “culture of silence” (Elwood, Greene, & Carter, 2003; Haubrich et al., 2004) to being conducive to both casual and personal conversations (Meunier, 2014, 2017). At women-only bathhouse events in Canada, organizers encouraged participants to negotiate verbally (Hammers, 2009). In MF lifestyle settings, negotiations can involve extended exchanges as consent is secured from multiple individuals. In the U.S., the phrase “taking one for the team” is used when one partner acquiesces to a sexual experience with a lower level of sexual desire than others. Although problematic if occurring frequently, the phrase reflects the predominant ethos of consent and personal responsibility found in the lifestyle (Harviainen & Frank, 2016). In BDSM, the roles (top/bottom), techniques (crop, bondage, etc.), and limits of a scene are ideally and typically discussed beforehand; a “safeword” can signal that a limit has been reached (Kaak, 2016; Newmahr, 2011). The phrase “safe, sane, and consensual” is one way that practitioners evaluate scenes without defaulting to mainstream definitions of acceptable behavior, as the focus on consent ideally differentiates power play from abuse for both participants and observers.

Social obligations also vary across environments, such as whether anonymity is expected, what personal information is exchanged in sexual negotiations or casual conversations, or whether participants consider themselves part of a community (Bullock, 2004; O’Leary, Horvath, & Rosser, 2013; Qian, 2014; Villaamil & Jociles, 2011). Private parties bring people together in condensed space and time compared to SOPVs, leading to increased socialization and sometimes, elevated feelings of responsibility toward partners. Reasons for socializing onsite vary—for example, participants may be seeking ongoing friendships, evaluating potential partners, or simply engaging in conversation to take a break from sexual activity (Meunier, 2017). However, in both MSM and MF settings, sex and sociality are not necessarily linked on or off-premises; individuals sometimes develop affectionate friendships with sex partners and with those whom they are not intimate (Frank, 2008; Meunier, 2014, 2017). Regardless of variation between and within collective sex environments, an expectation not to “out” other participants in everyday circles is widespread.

Substance use can be an incidental or intentional aspect of sociosexual interaction. Many BDSM events are substance free, given the focus on safety and technique. Collective sex participants may personally abstain from or limit substance use to ensure social or sexual performance or avoid misunderstandings (O’Byrne & Watts, 2011; Meunier, 2014). Certain substances, including alcohol, are a better “fit” for particular purposes—such as crystal methamphetamine and sildenafil for sexual stamina or ketamine for “bottoming” among MSM (Green & Halkitis, 2006; Palamar, King, Storholm, & Halkitis, 2012). Distinct enclaves also form involving not just sex and drugs but complementary auditory, tactile, or olfactory stimulation. “PNP,” “Wired Play,” and “ChemSex” refer to the use of drugs such as crystal methamphetamine during social and sexual activity, which may include “chilling, chatting, watching porn, browsing profiles, and a range of other group and individual activities” (Race, 2015)—generally in private settings. In MF environments, men and women also use or combine substances, including “club drugs,” to maximize social and sexual effects, often in private settings (Frank, 2013; O’Byrne & Watts, 2011). Whether such enclaves are loosely organized and transient or highly integrated, risk reduction practices and information sharing networks also develop (Friedman et al., 2011; Race, 2017).

When participants cannot control access to an environment, as in PSEs, they have less ability to manipulate space or to create and enforce situational norms (Tewksbury, 1996), while environments where access is controlled can cultivate highly specific codes of conduct. Biohazard Men, an HIV+ party, and the Fickstutenmarkt, a recurring, safer sex, stallion/mare themed event, both require applications and prior acknowledgement of rules regarding consent, sexual practices, communication, responsibility, and appearance. Participants at Biohazard Men agree not to “engage in any discussion regarding HIV- or health status, nor in any conversation about illness or medication” onsite. Scenes based on the development of skill or specialized knowledge, such as BDSM, can become relatively organized, even hierarchical, as participants need to display competency. Others, like “Party-n-Play,” are more loosely coordinated with few barriers to entry, even as some similarities have emerged among PNP sex seekers in self-presentation, ideals, preferences, symbols, and language use over time, online and in physical venues (Frederick & Perrone, 2014). Some participants are heavily influenced by onsite collective norms, even changing their individual practices over time, while other participants experience a discrepancy between their individual desires and the collective norms of an environment (Meunier, 2017). Norms also exert a stronger influence when participants are committed to a community or identity or when the overall scene is small—if there are few local venues, individuals who transgress norms may find themselves ostracized (Harviainen & Frank, 2016). However, individuals who wish to engage in “unacceptable” behavior, whether drug use, “unsafe sex,” or other activities, can then create new spaces in which to do so.

Misunderstandings, breaches of behavioral or communication norms, and occasionally even incidents of harassment or assault occur in collective sex environments. Some breaches, such as talking too loudly in a sexual zone, are relatively benign. Other breaches are more serious: sexual activity may cease when a newcomer appears suspicious in a PSE; violators of “house rules” or “safe words” may be asked to leave a venue or blacklisted (Bentzen & Træen, 2014; Holt, 2016). If an individual decides to forgo selecting his or her own sex partners or activities in any recreational environment, this deviates from the norm of obtaining ongoing consent to such an extent that it often requires either a partner to support this intention—as when a “master” orders a “slave” to service patrons—or special positioning such as the use of a glory hole, dark room, or themed area.

Although the cues, symbols, and gestures used to negotiate sex in collective sex environments are sometimes theorized as “subcultural,” Krol (1990) argues that PSE participants essentially use conventional communication tools for unconventional purposes. Across collective sex environments, it turns out that people need little initial training or acculturation to navigate space and negotiate sexual activity, even when visiting multiple locales or when traveling. Nonverbal behavior allows for effective communication of sexual intentions and interest across groups with only slight variations. Newcomers to any environment learn how to act through observation, trial and error, and occasionally through explicit instruction (books, workshops, online networks, or mentors); experienced individuals eventually develop more nuanced understandings or “literacies” (Frankis & Flowers, 2009; Harviainen, 2015; Kimberly & Hans, 2017).

This brief discussion cannot do justice to the complexities of spatial and social organization across collective sex environments, practices, and sexualities. The point, however, is that transgressive behavior does not unfold in random or senseless ways. We may never again find a public park where men have sex in a cove, down a hidden ravine, while leaning against an uprooted tree. Yet, across time and place, patterns in spatial and social organization arise as participants seek others with similar aims while striving for physical, social, and psychological safety. This insight has implications for thinking about our understanding of risk.

Section III: Rethinking Risk in Collective Sex Environments: Using Insights from an Inclusive Perspective

Theoretical Consistency: The Case of “Swingers”

Some research is based on an assumption that individuals who engage in certain non-normative sexual practices are homogeneous and distinct from those who do not. This assumption becomes especially problematic when researchers study only within self-identified alternative sexual communities or in particular field sites. Without a comparative perspective, the precise ways that sexual enclaves are distinct from each other and the mainstream (or not) can be eclipsed by our expectations.

After all, the crux of subcultural analysis varies with theoretical tradition. Classic Marxist or materialist theories of subculture centered on shared demographics or experiences of geographic or economic marginalization that positioned members as outside of or resistant to the mainstream. Symbolic interactionist theories emphasized how and why certain groups adopt beliefs, values, practices, and identities divergent from the mainstream. Over the last few decades, critics challenged the idea that groups could be bounded, internally homogeneous, and independent of the mainstream. Postmodern (or “post-subculture”) approaches began focusing more on lifestyle choices, consumption patterns, fashion, appearance, and self-identity, sometimes using new language (“scenes”; “fields”) to conceptualize how groups of individuals converge in real and virtual spaces for similar purposes, developing some unique shared understandings and practices, but with varying degrees of commitment and fluid memberships (Blackman, 2014). This is an abridged synopsis of a range of approaches; however, it highlights the fact that regardless of whether an analysis focuses on the physical location where a group of individuals congregates, a set of shared practices (“party and play”), or on the characteristics associated with an identity (“barebacker”)—a relationship between the specified group and “everyone else” is implied. Theoretical consistency requires making this relationship explicit.

Consider the case of “swingers.” Dutch STI clinics began voluntarily registering swingers in 2006, using questions about identity (“Are you a swinger?”) and behavior (“Do you practice partner-swapping?”). Data from 2007 to 2008 showed higher rates of chlamydia (CT) and gonorrhea (NG) (13.7%) among older swingers (> 45 years old) than in MSM or prostitutes, prompting suggestions that swingers be targeted as a high-risk group (Dukers-Muijrers et al., 2010). No other STIs were detected. After publication, public health alarms were sounded about elevated rates of STIs, “high-risk behavior,” and dangerous network connectivity among swingers by academics and the popular media (Mercer, 2017; Niekamp, Mercken, Hoebe, & Dukers-Muijrers, 2013).

Yet, who exactly are swingers? Dukers-Muijrers et al. (2010) defined swingers as individuals who identify as heterosexual and have sex with other heterosexuals as a couple. Other researchers locate a swinging “subculture” in the use of certain sex clubs or lifestyle Web sites by MF, coupled or not (Niekamp et al., 2013; O’Byrne & Watts, 2011; Platteau et al., 2017). Still other studies rely on self-identification as a swinger (Bentzen & Træen, 2014; Kimberly & Hans, 2017), which is slightly problematic given that even some MF participating in organized lifestyle events or practicing coupled extradyadic sex reject the term (Frank, 2007). But most importantly, does having sex “as a couple,” using certain venues, or identifying as a “swinger” have unique epidemiological importance that differentiates these encounters from those of individuals engaging in multiple casual hookups, threesomes, group sex, or sexual infidelity? Perhaps. However, that epidemiological importance is not immediately apparent.

Sensationalizing citation practices can also foreclose a deeper understanding of what is at stake. Dukers-Muijrers et al. (2010) is cited repeatedly as evidence of a high STI prevalence for swingers overall, for example, not just in older age brackets (Niekamp et al., 2013; O’Byrne & Watts, 2011; van Liere, Hoebe, Niekamp, Koedijk, & Dukers-Muijrers, 2013). Using follow-up data from two Dutch clinics from 2010 to 2013, Dukers-Muijrers et al. (2017) found that STI positivity in swingers was lower than MSM and heterosexuals overall; only when analyzed by age did swingers have higher CT rates than older heterosexuals. In a non-clinic sample of self-identified swingers (n = 2103), Fernandes and Gaither (2015) stated that chlamydia and HPV are the most frequently noted STIs in the U.S. general population. Less than 2% of men and 3.4% of women in their sample reported ever contracting chlamydia or gonorrhea during swinging; these STI rates are low compared to those found among the not necessarily coupled, economically marginalized, MF GSE participants studied by Friedman et al. (2008, 2017) and Zule et al. (2007). A sample from a swingers’ club in Canada (n = 101) found 20% of respondents reporting a lifetime STI diagnosis (6.9% chlamydia, 4.2% gonorrhea, 1.4% syphilis, 8.3% “genital warts,” and 4.2% genital herpes) with almost 50% regularly testing (O’Byrne & Watts, 2011). Platteau et al. (2017) report that 80% of their sample (n = 480; recruited from swingers’ clubs and Web sites) had been tested for STIs; rates of chlamydia (14.4%) and gonorrhea (6.4%) in the sample were in line with the general European population, although higher than the general Belgian population. STI rates are affected by testing patterns, especially with asymptomatic infections, as well as national regulations and screening, diagnostic and reporting capabilities, making some comparisons problematic. Yet, as chlamydia and gonorrhea are among the most common STIs for sexually active heterosexuals, with rates increasing globally in individuals aged 45–64 (Minichiello, Rahman, Hawkes, & Pitts, 2012; Monsell & McLuskey, 2016), it is not clear that swingers are distinctive based on STI prevalence.

Are swingers distinctive because of high-risk sexual behavior or dangerous network connectivity? STI screening recommendations already include anyone with more than one sexual partner. Although some swingers certainly engage in condomless vaginal or anal sex with casual partners, older heterosexuals are less likely to use condoms in general (Tuddenham, Page, Chaulk, Lobe,& Ghanem, 2017). Bentzen and Træen’s (2014) study of 12 self-identified swingers has been cited as evidence that “many swingers choose not to use condoms consistently” (Kimberly & Hans, 2017; Mercer, 2017), even though “none of the informants under 45 years of age was open to swinging without using a condom” and it is unclear how many of their 12 respondents fell into this age bracket. Kimberly and Hans (2017) refer to a “heightened risk among swingers for contracting and spreading STIs” based on 6 respondents in their sample who “preferred to not use condoms” (20% of 34 respondents); however, condom use in their sample overall was slightly higher than among MF in general in the U.S. (20–25%, depending on the study; see Nasrullah, Oraka, Chavez, Johnson, & DiNenno, 2017; Reece et al., 2010). That some self- or researcher-identified swingers are not using condoms does not alone meaningfully distinguish them from other highly sexual MF with concurrent partners, marginalized drug-using urban youth (Friedman et al., 2008), teen gang members (Dickson-Gomez et al., 2017), women engaged in “survival sex” (Stratford, Ellerbrock, & Chamblee, 2007), or young adult MF club drug users (Buttram & Kurtz, 2015). Swingers may indeed have distinctive sexual networks rooted in practices, identities, or venue use patterns, and as sexual concurrency leads to higher sexual network connectivity, these networks could be associated with rapid STI transmission. Whether that is the case, however, is an empirical question requiring analysis of actual sexual networks rather than social or affiliation networks—along with an actual STI outbreak.

Of course, notable differences in health behavior can arise between people who participate in different types of sexual practices, and between those who participate in non-normative sexual practices and those who do not. Consensual non-monogamy (or CNM) includes swinging, polyamory, and other types of non-exclusive sexual arrangements. CNM individuals appear to be more highly sexual than their monogamous counterparts. A study comparing 502 self-identified CNM respondents with 723 similar respondents from the nationally representative 2012 United States General Social Survey (GSS; http://gss.norc.org) found that CNM respondents reported significantly more sexual frequency and more sexual partners in the past 12 months—an average of about 3 sexual partners in comparison with less than 1 partner for GSS respondents (Fleckenstein & Cox, 2015). CNM respondents were also more than three times as likely to have had an HIV test as GSS respondents (the only question about sexual health which could be compared) suggesting a “greater awareness of and commitment to safe sexual health practices” (Fleckenstein & Cox, 2015). Lehmiller (2015) found that people in CNM relationships had a greater number of lifetime sexual partners than those in monogamous relationships, but higher condom use with both primary and extradyadic partners and higher rates of STI testing; rates of STI diagnoses were similar in both groups. Frequent testing is also mentioned in studies of self-identified swingers (Dukers-Muijrers et al., 2017; Kimberly & Hans, 2017; O’Byrne & Watts, 2011; Platteau et al., 2017). Further, CNM is based on an ethical ideal of honesty and transparency about sexual practices. Some evidence indicates that CNM individuals talk about sex more frequently than those in traditional relationships and become comfortable addressing taboo subjects (Fleckenstein & Cox, 2015; Frank & DeLamater, 2010; Sheff, 2006). Comparing consensual non-monogamists with sexually unfaithful individuals, Conley, Moors, Ziegler, and Karathanasis, (2012) found that sexually unfaithful individuals engaged in more risky sexual behaviors with extradyadic partners, were more likely to use drugs and alcohol, and were less likely to use condoms for vaginal or anal sex, sanitize sex toys properly, and to inform their primary partner of the reported encounter.

As local, national, and even international communities develop around sexual practices and preferences, participants sometimes develop other shared beliefs, values, esthetics, identities, and non-sexual practices—and some of these shared elements will matter for HIV/STI transmission. The process of targeting involves identifying risky places or risky people as “in need of ‘intervention’” and naming them (Batrouney, 2009). As the lens narrows, however, distinctiveness can be taken for granted rather than established: swinging becomes viewed as a ticking time bomb for STIs rather than a set of sexual and recreational practices that has been evolving for at least half a century among a relatively privileged demographic; “chemsex” appears as a harrowing new subcultural phenomenon among gay men rather than the latest example of how sex and drugs and have been combined in both gay and mainstream environments for decades to intensify the physical or emotional experience of both. The relevant distinctiveness of the MF groups discussed above does not lie in whether individuals are sexually exclusive or have multiple partners, visit certain venues, or identify as swingers, but in the other health and communication practices that shape their sexual encounters, actual sexual practices and network connections. Some of these practices may indeed provide a foundation for claiming epidemiological distinctiveness—regular communication about sexual matters, transparency with sexual partners, and frequent STI testing, for example.

Widening the analytical lens to account for a broader analysis of material conditions beyond immediate context (location of sex) is also important. Some work on MSM already presents a complex understanding of group differences, examining the link between socioeconomic disconnection and HIV status in MSM (Gayles, Kuhns, Kwon, Mustanski, & Garofalo, 2016), racial disparities in HIV infection (Mustanski, Birkett, Kuhns, Latkin, & Muth, 2015), or linking syndemics to social and economic marginalization (Adam, 2016; Mimiaga et al., 2015b)—however, these approaches are less visible in the work on collective sex. Even Friedman et al.’s (2008) Bushwick study or Friedman et al.’s (2011) ethnographic study of GSEs—both of which discuss urban GSEs among unemployed and employed IDU and non-injecting drug users, jobless “poor people,” high-risk youth, mixed groups of “straight men, gays, and women (including lesbians)” who have sex together—end up suggesting that GSEs overall are the “risk environments” rather than the broader context of inequality in which these particular GSEs occurred. Attention to the broader social and economic context complements studies that zero in on statistically precise risk groups or visibly non-normative environments. As persistent associations of non-normative sex with disease and risk exist not just in the public sphere but also in academic discourse, affecting data collection, analysis, citation practices, and the dissemination of research findings, theoretical precision can complement statistical associations to produce more balanced interpretations. Although it is admittedly difficult to design interventions that address poverty, unemployment, community violence, limited educational opportunities, or how marginalization interacts with beliefs and relationships to shape sexual practices (Dickson-Gomez et al., 2017), our theories and concepts must take these factors into account. Otherwise, we may end up pursuing groups of “jeans”-wearers (Matser et al., 2013) or “swingers” that are artifacts of how data are collected and analyzed rather than meaningfully distinct populations.

Practical Implications

Statistically, certain highly sexual groups of MSM—especially those engaging in combinations of sex and drug practices—are more at risk of HIV and other STIs even if those same combinations of practices do not lead to epidemics in other populations. Interventions in collective sex environments arguably reach some of these individuals, as well as marginalized populations not accessible elsewhere, offering access to free condoms, STI testing, or other services (Daskalakis et al., 2009). Being labeled “high-risk” might benefit certain individuals through increased eligibility for diagnostic tests or preventive treatments, depending on the medical system. However, an inclusive perspective suggests rethinking the emphasis on interventions in collective sex environments for practical reasons in addition to the theoretical reasons discussed in the previous section.

Not the Time or the Place

First, the general spatial and social organization of collective sex environments will hinder onsite outreach and intervention attempts. As illustrated in Section II, participants across collective sex environments exhibit concern with the management of exposure and with ascertaining intentions and consent. Gatekeeping, spatial segmentation and progression, and the emergence of behavioral norms all help ensure that individuals who access collective sex environments do so intentionally—one does not end up inside a sex club, much less in a “dark room” or at a “POZ party,” by accident. At least some individuals engaged in behavior that is defined as “risky,” or is illegal or stigmatizing, will use the preexisting spatial and social organization of collective sex environments to purposely ignore or evade onsite outreach attempts, even retreating to settings with more barriers to entry such as private homes or invitation-only, pre-screened, or themed events.

Second, patrons of PSEs, SOPVs, and sex parties tend to select environments offering opportunities for the sex and socializing they prefer (Mimiaga et al., 2010; Reidy et al., 2009; Villaamil & Jociles, 2011; Woods et al., 2007). Some individuals intentionally choose private sex parties where there is a lack of onsite discussion of sexual health or to avoid the rules and staff monitoring found in bathhouses (Mimiaga et al., 2010); other participants select collective sex environments that support desires for condom use or other safer sex practices. Even “spontaneous” GSEs—“hang out, use drugs, then sex happens” (Welych et al., 1998)—have intentional elements. Where the “hanging out” occurs, which drugs are used, which sexual activities transpire, and which other people are present are not accidental. Spontaneous GSEs have been associated with more receptive UAI and substance use than organized events (Grov et al., 2013b), but what matters is not necessarily how a “spontaneous” event is defined in comparison with an “organized” one by researchers, but that participants understand or desire to justify their behavior as unplanned.

It is beyond the scope of this paper to delve into the full range of social and psychological reasons that sexual risk-taking persists despite prevention efforts: lack of education; economic hardship making concern over HIV/STI risk secondary to survival; social and relational inequalities that constrain decision-making (Dietrich et al., 2011; Justman et al., 2015); the erotics of certain sexual roles (Moskowitz, Seal, Rintamaki, & Rieger, 2011); desires to break taboos (Bollen & McInnes, 2004); risk compensation, treatment optimism, or prevention fatigue (Ávila, 2015; Velter et al., 2013); discomfort discussing sexual health (McInnes, Bradley, & Prestage, 2009); pursuit of cognitive escape or transcendent experience (Groes-Green, 2010); masculine discourses valorizing competition, strength, and risk-taking (Adam, 2016); and so on. Although participants tend to access any given collective sex environment intentionally, individual intentions for onsite risk-taking may still vary. Some individuals intend on practicing safer sex, using condoms, or avoiding substance use regardless of the location of sex or the expectations of other patrons, for example (Meunier, 2017). Some participants may also misunderstand the potential risks involved with particular practices or engage in unintended onsite risk behavior due to contextual influences or incorrect assumptions about the serostatus of a partner (Meunier & Siegel, 2017). However, some of the risk-taking that occurs in collective sex environments appears to be intentional, or “conscious risk.” The minority of MSM engaging in risky sexual behavior in collective sex environments seem to engage in more risk behaviors overall (Prestage et al., 2011; Solomon et al., 2011). Mimiaga et al. (2010) suggest that some men have a ‘‘risk-oriented’’ tenor to their lives in general, given the substance use patterns they observed among sex party attendees. PrEP use may eventually make condomless sex normative at some venues for MSM; however, PrEP is already targeted at conscious risk-takers. Conscious risk-takers are familiar with safe sex information and STI testing, fairly accurate at perceiving whether they are high risk, and willing to engage in some level of risk-taking wherever they have sex (Chen et al., 2013; Mimiaga et al., 2011; Petersson, Tikkanen, & Schmidt, 2016; Prestage et al., 2009b; Zablotska et al., 2014). Such individuals may reject or reframe public health arguments about risk, compare sexual risk-taking to other risky activity, share information, and adopt risk reduction practices (Cheung et al., 2015; Hurley & Prestage, 2009; Pollock & Halkitis, 2009; Race, 2015; Rusow et al., 2017). Meunier (2014) observed that regardless of sex party attendees’ behavioral choices—“playing raw” only with HIV-positive partners, never asking about someone’s HIV status, positioning as a top or bottom, etc.—they had clear boundaries and justified them.

Among individuals who calculate risk, operate with “a sense of sexual ethics,” and consider themselves informed, admonishments to “always wear a condom,” warnings about the risks of oral sex, or a vilification of substance use can come off as hypocritical or condescending; many men engaging in sexually adventurous scenes become “at best, ambivalent,” and “at worst, hostile and mistrustful” of prevention efforts (Batrouney, 2009). Grov et al. (2014b) point out the “logistical challenges” of outreach at sex parties in private residences or hotel rooms, such as finding relatively private spaces to interact with patrons or knowing when or where a party is being held. As attendees reported that seeing medical providers or peer outreach workers at parties was unacceptable, the researchers instead suggest that providers “consider collaborating with party organizers to deliver programs, and reach out to party attendees as they enter or leave.” But if outreach workers are not welcome at the party, it seems unlikely that attendees want to encounter them when heading home, either. Individual, group, or structural interventions targeted at this segment of occasionally drug-using, sexual risk-takers may admittedly have limited success, and even be viewed as stigmatizing (Hirshfield et al., 2015).

Improving communication practices and increasing health protective behavior in collective sex environments requires the development of sexual health literacy and communication practices more generally. For those individuals who do accidentally stumble into a barebacking event, engage in spontaneous group sex after imbibing disinhibiting substances, or take unintentional risks after being swept up in the atmosphere of a sex party, the tools necessary for making informed decisions about their sexual health in that moment were most likely acquired beforehand. Meunier (2017) suggests that off-site interventions with MSM who go to sex parties could be successful not simply by promoting discussion of condom use or HIV/STI status at sex parties, but by increasing awareness of the different collective norms that attendees may encounter at sex parties and of how to manage discrepancies between these collective norms and their individual norms (p. 10). Negotiating such discrepancies, however, is also crucial in dyadic encounters, where individual intentions to use condoms may be thwarted by broader social norms preventing open discussion of sexual health or linking condomless sex to commitment. Global STI/HIV education and prevention efforts have been suggested for MSM regardless of where they have sex or find sexual partners (Grov et al., 2013a, b). Adolescents in general are high risk of STIs (Victor, Chung, & Thompson, 2015), but young MSM face intensified health risks that suggest the need for early, innovative interventions—family-based HIV prevention approaches, computer- or technology-based behavioral interventions, biomedical interventions, and so on (Garofalo, Mustanski, & Donenberg, 2008; Mustanski, Newcomb, Du Bois, Garcia, & Grov, 2011b). These interventions would ideally both precede the use of collective sex environments and influence interactions onsite.

Collective sex environments in general may not be private enough for most people to undergo testing comfortably. STIs are already stigmatized, leading to a general reluctance toward testing and informing partners of results (Conley, Moors, Matsick, & Ziegler, 2015); the persistent association of non-normative sexuality with disease compounds a situation already fraught with shame and fear. Onsite interventions with MSM produce varied results, depending on the locale (Schwitters & Sondag, 2017; Strömdahl et al., 2015; Velter et al., 2013). Some studies have found that onsite HIV/STD testing has yielded low uptake and low positive results, suggesting that “persons likeliest to harbor the infection may be the least likely to seek testing” (Wohlfeiler & Potterat, 2005: S49; Ciesielski et al., 2005). A 5-year intervention (402 h) resulted in just fifteen persons requesting onsite testing (Debattista, 2015), and a 6-month study incentivizing SOPV patrons to undergo STI testing at a clinic generated just two new clients and detected one case of rectal chlamydia (Stevens, Debattista, & Rutkin, 2013).

However, other settings are already more promising, as young MSM can be reached in low-risk venues such as coffee shops or recreation centers (Holloway, Rice, & Kipke, 2014). Many highly sexual individuals, and those using collective sex environments, can also be reached online (Grov & Crow, 2012; Grov et al., 2013a; Klein, 2013; Landovitz et al., 2013; Wei et al., 2014), which is an appropriate venue for outreach given that disclosure of serostatus, viral load, and sexual preferences are increasingly negotiated through the Internet or mobile technology. Technological innovation enables new forms of relating that might be harnessed for HIV/STI prevention, such as “buddy lists” to maintain contact with casual partners (Race, 2015). As PrEP is meant to be part of a comprehensive HIV prevention package, STI screening frequency could be improved among these high-risk men in clinical settings (Scott & Klausner, 2016).

Stigmatization

Second, onsite intervention increases stigmatization of participants more generally, regardless of whether they engage in risk behavior, and strengthens misleading assumptions about collective sex. Most users of collective sex environments are not taking risks onsite or elsewhere—especially if risk-taking is assessed by actual practices such as UI rather than being defined a priori as multiple sex partners or venue use. Yet users are pathologized anyway; many fear legal or social consequences if exposed (Hennelly, 2010; Vaillancourt & Few-Demo, 2014). Participants in non-normative sex often feel uncomfortable talking with health professionals about their sexual practices (Adam, 2016; Kimberly & Hans, 2017; Prestage et al., 2009c)—and for good reasons. Well-meaning suggestions that “at-risk” individuals be asked about illegal drug use and detailed sexual behavior during medical visits may unfortunately have negative repercussions for health insurance coverage, and medical records may not remain confidential despite regulations (Schwitters & Sondag, 2017). Assumptions about the risks of collective sexuality affect the responses of doctors, therapists, and other professionals to disclosures.

The perception of collective sex as inherently riskier than dyadic, domestic sex is pervasive, even as nearly 80% of HIV transmissions among MSM occur in primary relationships (Sullivan, Salazar, Buchbinder, & Sanchez, 2009), and this perception impacts safe sex practices. Some participants view their own behavior negatively, describing themselves or other participants as “dirty” and creating hierarchies of venues (“seedy”; “exclusive”) and patrons (“dirty”; “clean”); they may also be less likely to engage in protective behaviors (Richters, 2007; Villaamil & Jociles, 2011). Relationship type was found to be a larger within-person predictor of unprotected sex among young MSM than drug use prior to sex (Mustanski, Newcomb, & Clerkin, 2011a), and both MSM and MF adjust their safer sex strategies and disclosures by distinguishing between primary partners, casual partners that are known or trusted, “one-night stands,” strangers, and so on (Chen et al., 2013; Prestage, Jin, Grulich, de Wit, & Zablotska, 2012; van den Boom, Stolte, Sandfort, & Davidovich, 2012). Individuals who worry that condom use implies mistrust of a partner or would raise suspicion about their own behavior are also more likely to have condomless sex as the symbolic statement that condom use makes about a relationship can override other concerns (Cai & Lau, 2014; Tavory & Swidler, 2009). Symbolic decisions, however, do not account for the fact that actual risk lies not in whether one is having sex with a primary partner or a stranger, in a “dirty” sex club or in one’s own bedroom, but rather in the presence of infection, type of infection, whether the sexual practices engaged in could lead to transmission, and what happens after that.

After all, many of the components of risk-taking found in collective sex are not subcultural but cultural—if “culture” is defined as widely shared or dominant meanings, beliefs, values, social practices, etc. It is not only in collective sex environments that people who want to have sex tend to turn down the lights, turn up the music, and speak more softly—if they speak at all. It is not only in collective sex environments that people sometimes forgo a condom “in the heat of the moment,” because one is not readily available, or because asking for a condom is uncomfortable. It is not only in collective sex environments that people are reluctant to disclose an STI diagnosis for fear of rejection, or worry that discussing safer sex practices—even requesting something as simple as hand washing—will “ruin the mood.” Richters (2007) argues that “commercial sex venues have features that disrupt the kinds of social interaction that regulate and prevent sex happening in other settings”: the setting is safe from intrusion or violence, the situation is defined as sexual, everyone present is a potential sexual actor, and the atmosphere is warm and dark (reminding us “of the bedroom, of night, of being unobserved”). But this observation might productively be phrased in reverse: sex, wherever it occurs, has an underlying logic. The social and sexual activity unfolding in collective sex environments is transgressive in some ways—occurring between multiple partners, with various configurations of witnessing and being witnessed, and outside of domestic spaces—but is not unlike sex occurring elsewhere in other important ways.

Section IV: New Directions, Limitations, and Conclusions

Admittedly, given that sources of funding for research in public health or HIV/STI prevention are more prevalent than for other research questions, scholars face institutional pressure to focus on sexual risk-taking, especially at the beginning of their careers. Scholars may also find abundant opportunities for publication in journals dedicated to HIV prevention, epidemiology, infectious diseases, and so on, where literally thousands of pages are printed each year devoted to this conversation. Laying claim to an intellectual niche is a practical and rhetorical process—identifying, naming, and studying increasingly particular populations or practices to address gaps in the literature—as well as a path to a productive academic career. Given these institutional realities, and the fact that HIV and other STIs remain a public health issue worthy of academic attention, we might think about slightly shifting course rather than jumping ship. When it comes to collective sex, what we already know about risk suggests the need for generating additional research directions through comparative analysis or by widening our analytical lens. Rethinking the unrelenting emphasis on risk also opens the doors to use insights generated from collective sexual environments to tackle other sociosexual issues ranging from STI prevention to the negotiation of consent.

Why and how STI rates are controlled in some highly sexual enclaves, rather than spiraling out of control as in theoretical projections, might be considered. The U.S. adult film industry, for example, has managed STIs among MF performers using regular testing, treatment, and informing sexual partners—not by promoting behavioral change; this type of model may be more commonplace in the future if PrEP becomes widespread among MSM. Folk knowledge and existing risk reduction practices might be seriously evaluated. The long-standing tradition of providing of Listerine mouthwash in some MF and MSM collective sex environments has recently been bolstered by research suggesting its utility as a non-condom based control measure for gonorrhea (Chow et al., 2017).

Some GSE participants, SOPV users, and swingers should be studied as models for raising STI testing rates among young adults. Overall, 97.1% of MSM GSE attendees have tested for HIV (Phillips et al., 2014); 93.7% of users at “cruising venues” have tested for HIV (Gama et al., 2017); 88% of bathhouse users have tested for HIV (Daskalakis et al., 2009); and 79.8% of swingers have tested for STIs, with 71.9% testing in the last year (Platteau et al., 2017). These rates are far higher than those found among young adults (15–25 years) in the USA more generally, with 16.6% of females and 6.1% of males having ever been tested for STIs (Cuffe, Newton-Levinson, Gift, McFarlane, & Leichliter, 2016). Certainly, higher rates can be partially attributed to successful education, prevention, and outreach campaigns; however, internal motivations for attending to sexual health should be explored. Increasing the number of adolescents and young adults tested and treated for STIs, and vaccinating all youth for HPV at ages 11–12 years as the CDC (2016) recommends,2 would produce benefits across sexual orientations.

A realistic assessment of the actual risks involved with most STIs is also warranted. In fact, such assessments are already made by MSM and MF conscious risk-takers—although often in a context of shame, fear, and limited information. As Conley et al. (2015) argue, it may be that “the extensive public health focus on preventing STIs (both based on the amount of resources utilized for STI prevention and in the importance of STI prevention in the American psyche) is inappropriate, given the actual level of risk posed by sexual activity.” At the same time, a more balanced assessment of the health implications of collective sex might include research on non-sexually transmitted infections—infectious mononucleosis, influenza, group A streptococcus, and others—as well as STIs.

The potentially life-affirming aspects of collective sex—the experience of community, enhanced self-esteem, adventure, pleasure, etc.—should not be obscured by a public health focus on the dangers (Groes-Green, 2010; Race, 2017). Communities and networks provide support and facilitate protective behavior as well as risk behavior (Amirkhanian, 2014; Cooper, 2007), and feelings of connectedness can impact sexual risk-taking through communication practices and a sense of responsibility. During the early years of the HIV epidemic, the safe sex materials developed within the gay community were arguably influential in prevention (Bolton, Vincke, & Mak, 1994). Even some of the “riskiest” barebacking events are designed to facilitate the exchange of sexual health information before physical contact or to explicitly allow participants to opt in or out of practices that increase transmission risk. Feelings of responsibility can extend to emotional exchanges as well. The concept of “aftercare” in BDSM involves checking in with a partner to clear up misunderstandings and offer emotional support when necessary, before an experience is reframed as harmful (Holt, 2016). If such a concept were brought to bear on sexual encounters more generally, the recognition that one can—and should—care for even a casual partner emotionally could prove beneficial. Some collective sex environments foster supportive contexts for overcoming shame, communicating about desire and safety, and developing sexual techniques (Hammers, 2008; Smith et al., 2010). Collective sex participants can watch other people negotiate and have sex—an uncommon experience across cultures—and explore physically, emotionally, and in terms of sexual or community identity (Albury, 2015; Meunier, 2014; Scoats, Joseph, & Anderson, 2018).

Future research might also examine how consent is negotiated and interpreted in collective sex environments in ways that differ from the mainstream. Sexual consent is portrayed as a somewhat mysterious and illusory achievement between college students, for example. Mainstream commentators on campus affirmative consent standards worry about a “gray area” between persuasion and consent, or that requiring agreement at each stage of intimacy will drain the eroticism out of sex (see Dalmia, 2014). Yet consent can be negotiated nonverbally in a PSE among strangers without “killing the mood,” and an understanding of consent as an ongoing process—without obligations to continue or be inclusive—is widespread in collective sex environments (Klement, Sararin, & Lee, 2017; Pitagora, 2013; Williams, Thomas, Prior, & Christensen, 2014), contrasting with “hookup” scenes where alcohol or drugs may be used to overcome shame or guilt or to persuade reluctant partners (Boyle & Walker, 2016). If every college or university maintained an SOPV for students where condoms were readily available, substance use was monitored, and explicit rules guided interactions, perhaps some of the contemporary crisis around consent on campus would be alleviated. Students who used the SOPV—even if only for dyadic encounters—would gain an understanding of how consent can be explicit and continually negotiated. The flip side to obtaining consent is taking responsibility for saying either “yes” or “no” to sexual activity; witnesses could offer protective benefits on both sides of the negotiation (of course, individuals not interested in abiding by such expectations would probably retreat to private venues).

Limitations

Given differential health risks facing MSM and MF populations, disparities in HIV/STI rates across racial and ethnic groups, and international variation in sexual practices and the impact of HIV/STIs, an inclusive analysis necessarily elides some important nuances. Discussing curable STIs alongside a viral epidemic such as HIV poses limitations as well, as the severity of outcomes are not comparable; HIV and other STIs can also interact such that transmission risks become complex. Among populations with severely limited access to health care, the risks of even treatable STIs are compounded; as HIV becomes a chronic disease among certain groups, changes will become necessary in terms of economic and medical intervention. Due to an inevitable publishing lag, future studies may report that PrEP has caused more behavioral changes than are addressed here. This analysis is further limited due to the narrative, rather than comprehensive, nature of the literature review; however, I expect that additional observations in collective sex environments will support the patterns of spatial and social organization discussed in Section II.

Conclusion

Site-specific analyses of collective sex environments can challenge universalizing models of risk-taking, account for environmental or situational influences on behavior, and allow for interventions considering the unique characteristics of each setting and its users. Theoretically, however, an ever more detailed exploration of the relationship between environment and sexual risk-taking behavior eventually leads down a rabbit hole to infinite particularity. As each environment proves dynamic, with idiosyncratic features, “further research” is ultimately required everywhere. Still, as hundreds of studies have been undertaken in the last 50 years, ranging across types of environments and participant sexualities, some generalizations are possible. Considered inclusively, collective sex environments do not appear as inherently risky or even as riskier than private spaces overall. Although venue-specific characteristics affect whether, where, and how much sexual risk-taking occurs onsite, the minority of individuals engaging in risk behaviors in collective sex environments also engage in risk behaviors elsewhere, including during dyadic sex. An inclusive perspective also reveals similar patterns of spatial and sociosexual organization arising across collective sex environments due to their socially transgressive nature. These patterns suggest a need to theoretically and empirically elucidate the distinctiveness of sexual enclaves from each other, and from the mainstream, with respect to HIV/STI transmission risks and sexual risk-taking behavior—rather than assuming distinctiveness or defining collective sex a priori as risky. These patterns also suggest rethinking onsite interventions in collective sex environments. Gatekeeping, spatial segmentation and progression, and behavioral norms emerge to safeguard participants from hostile witnesses or accidental intruders while allowing them to ascertain the intentions of other users and negotiate sexual activity. At the same time, however, these same forms of spatial and sociosexual organization will shield the most transgressive, intentional risk-takers from witnesses—including outreach workers and researchers.

Footnotes

  1. 1.

    Micro versus macro is a common distinction in sociology to differentiate between theories that look at broader social structures or processes (politics, economy, etc.) and micro processes (interactions, emotions, etc.).

  2. 2.

Notes

Acknowledgments

I would like to thank the anonymous reviewers, along with Christian Grov, Edward Fernandes, Keith McNeal, and Paul Vasey for comments on earlier drafts of this paper.

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Authors and Affiliations

  1. 1.Department of SociologyUniversity of Nevada, Las VegasLas VegasUSA

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